Agony and ecstasy: Prescription drugs and overdose awareness

As the world marks International Overdose Awareness Day, GPs have a crucial role in helping to curb prescription drug misuse in Australia.

Latest research shows the most likely person to experience an accidental overdose in Australia is a middle-aged man living in a regional area.

‘It was [10] years ago … but to me it’s like it was yesterday.’

These are the words of Kim Ledger as he recalled the loss of his son Heath to an opioid overdose in January 2008.

The 28-year-old actor had been caught up in a punishing production schedule, flying between three different countries and filming scenes at night in the bitter cold. He contracted a chest infection that developed into pneumonia, and experienced insomnia. Heath visited a variety of doctors on his travels to help deal with these problems, collecting a veritable cornucopia of prescription medications, including opioids and sleeping pills.

Kim Ledger became a founding patron of ScriptWise following the accidental overdose death of his son, Heath, in 2008.

‘He took that combination, which he was warned about by his sister. Kate was always on the phone to him every day,’ Mr Ledger, a founding patron of Scriptwise, a non-profit organisation dedicated to reducing prescription medication misuse and overdose in Australia, told the RACGP.

‘That’s young men, they know everything and they’re absolutely invincible.

‘But that combination just happened to put him to sleep forever.’

In combination, the opioids, sleeping pills and the chest infection itself had a depressing effect on Heath’s respiratory system, causing it to shut down. This made him a high-profile casualty of what was emerging as a prescription opioid epidemic, which includes the use of legal drugs such as codeine, fentanyl and oxycodone.

While Heath’s death was the result of a medication mix he didn’t realise would exact such a heavy toll, other opioid users have a more long-term relationship with these types of drugs, often becoming unexpectedly addicted after using them as a treatment for chronic non-malignant pain.

‘The accidental addict. In a very short space of time, people can become addicted to oxycodone and products like that,’ Kim said.

Such was the case of 30-year-old nurse and mother of two, Katie Howman, found dead following a fentanyl overdose in her Toowoomba home just before Christmas in 2013. Investigations revealed she had visited 20 different doctors and 15 different pharmacies over the previous 13 months in her search for opioids.

Opioids – a category that includes pharmaceuticals such as oxycodone and fentanyl, as well as illicit versions such as heroin – remain the main cause of accidental overdose death in Australia. Opioid-related deaths hovered at around 450 per year at the turn of the century, but these numbers have risen sharply since 2006 to hit over 1100 per year since 2014.

What has led us to this epidemic, and what can GPs do to help curb it?

Too good to be true
In the late 1990s, prescription opioids seemed like an ideal answer to the often-difficult problem of chronic, non-malignant pain.

‘There was an increased demand to treat chronic pain. There were very few options and very little research that had been done on this problem,’ Dr Evan Ackermann, a GP with a special interest in opioids, told the RACGP.

‘This was mixed with a situation of some fairly aggressive drug company marketing of opioids and a change of clinical attitude towards pain. Normally, pain would be part of the healing process, but people started to say we should be looking at pain as the “fifth sign” and treating it aggressively.

‘It was a cultural shift across the healthcare sector, across the board, from pharmacy right through to general practice, specialists and hospitals.’

Dr Simon Holliday, a GP with a special interest pain management, is not surprised that opioids were considered so effective.

‘If you or I or anybody took opium or opioids, all our problems would go away,’ he told the RACGP. ‘They’re cure-alls – we all feel great when we use these drugs and they relieve our symptoms.

‘But the problem is, it’s all short-term and we now know that our problems will come back worse if we take this approach.’

L–R: Dr Hester Wilson and Dr Evan Ackermann agree that patients should be approached in a non-judgemental way when discussing drug misuse.

Dr Hester Wilson, GP and Chair of the RACGP Specific Interests Addiction Medicine network, has found that communicating honestly with patients about the risks of opioid use can also help them to consider other options.

‘By the time we’ve been through all the issues around the side-effects of opioids, the problems they can cause and things we need to put in place, patients generally say, “Actually, I don’t think I want to go for that, I’m going to continue with the psychology and the physio”,’ she told the RACGP.

Given opioids can be a hot-button topic and difficult to discuss with patients, Dr Ackermann believes that stigmatisation of the issue is not helpful and that patients should be approached in a non-judgemental way.

‘We’ve just got to be very careful as practitioners that we treat these people appropriately, and that’s with respect for those people who need services for ongoing, genuine pain, and also for those who have an iatrogenic dependence, or may have a substance-use disorder. We just need to be professional in addressing these issues.’

Dr Wilson agrees, illustrating her belief with her own clinical experience.

‘There is a sense out there sometimes that it’s just people choosing to do this, that there’s a dichotomy between the genuine-pain patient and the bad drug user,’ she said. ‘My experience is that they’re the same group of people.

‘Opioids interact with us as a species in a particular way; all of us are at risk of side-effects and one of those major side-effects is dependency and addiction.’